Beware the Code-Cart Epinephrine Syringes When Treating Kids

Trying to treat children in cardiac arrest with epinephrine from commercially-available, pre-filled syringes on the code cart likely overdoses them in most cases, researchers found.

Matt Hansen, MD, MCR, of Oregon Health & Science University in Portland, and colleagues evaluated 56 pre-filled epinephrine syringes used to resuscitate patients experiencing cardiac arrest, simulating direct injection from the syringe into an IV port and then a flush.

Pushing the stopper to the 0.5-mL mark for a child's dose actually expelled 0.90 mL on average (95% CI 0.85-0.96 mL) with a range of 0.50-1.30 mL, they reported online in JAMA Pediatrics. Only three out of the 56 syringes delivered volumes within 20% of 0.5 mL; 17 delivered volumes more than twice that.

"Administering a small volume of epinephrine directly from pre-filled syringes risks delivering more than the intended dose," the authors concluded. "Owing to limited accuracy, clinicians should transfer epinephrine to a smaller syringe for infant dosing. Manufacturers could also make devices to better meet the needs of pediatric patients."

For now, the former may be easier said than done. "I think it is not easy to justify transferring to smaller syringes during a code blue -- these are very time sensitive and we're already seeing large delays that are prognostically relevant. In addition, there may be a risk of delivering a lower than necessary dose due to losses in transfers," commented Rohan Khera, MD, of UT Southwestern Medical Center in Dallas.

"Moreover, the present study didn't directly address this scenario. So, I think, if their findings hold true in an independent study, physicians and industry would need to partner to develop an appropriate strategy that ensures reliable drug delivery, either with improved calibration of these syringes or pediatric-dose syringes," he told MedPage Today.

"I think this is a small but well-done study," Khera added. "More importantly, I think it questions a very intuitive scenario. If you are pushing in to the half-way mark in a 1 mL syringe, I think almost everybody would agree that you're delivering 0.5 ml worth of dose of any medication."

"While it makes sense for the drug delivery mechanisms to have a safety margin to account for the drug left in the tubing connected to the syringe, it is surprising that the amount ejected is so variable and often over twofold higher. I believe that for epinephrine, which has a narrow therapeutic window in resuscitation, this variability of dosing is extremely relevant."

Products investigated by Hansen's team were the LifeShield from Hospira (n=13) and the Luer-Jet Luer-Lock from International Medication Systems (n=43). The Luer-Jet syringes did slightly better, delivering 0.88 mL on average (compared with 0.98 mL from the LifeShield syringes).

When MedPage Today asked Hospira's parent company Pfizer to comment, the company produced the following statement: "Patient safety and the quality of our medicines are of utmost importance to Pfizer. Our medical experts are currently reviewing the just released study."

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